MEDI-CALELIGIBILITY PROCEDURES MANUAL
ARTICLE17
17A
17B
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MEDI-CAL SPECIAL TREATh4ENT PROGRAMS
INTRODUCTION
1.
BACKGROUND
2.
DEFlNmON OF DIALYSIS AND RELATED SERVICES
3.
DEFINITION OF TYPES OF DIALYSIS
4.
BENEFICIARY PORTlON OF SPECIAL TREATMENT PROGRAM COSTS
5.
OTHER HEALTH COVERAGE AND BILLING PROCESS
6.
MEDLCAL EUGIBILrrY DATA SYSTEMS (MEDS) PROCESS
ELlGlBlLrrY REQUIREMENTS AND PROCEDURES
1.
SPECIAL TREATMENT PROGRAMS- "ONLY GROUP
2.
SPECIAL TREATMENT PROGRAMSWSUPPLEMENT"
GROUP
3.
AID CODES
4.
INFORNlATlONON DIALYSIS AND TPN SERVICES
5.
DETERMINATION OF ANNUAL NET WORM FOR MEDI-CAL SPECIAL
TREATMENT PROGRAMS
6.
CUENT INFORMATION
MEDICARE ELIGIBILITY AND THE MEDI-CAL DIALYSIS SPECIAL TREATMENT
PROGRAMS
1.
IMPORTANCE OF MEDICARE FOR DIALYSIS ELIGIBLES
2.
MEDICARE EUGlBIUrY REQUIREMENTS FOR DIALYSIS PATIENTS
3.
WAITING PERIOD FOR MEDICARE COVERAGE
4.
MONITORING CHANGES IN MEDICARE ELIGIBILITY
5.
CLIENT RESPONSlBlLmES
6.
COUNTY RESPONSlBlLlTlES
7.
RETROACTIVE MEDICARE COVERAGEAND MEDI-CAL OVERPAYMENTS
MANUAL LEllER NO.: 187
DATE: se?t-'-. 13,1997 -3RGEARnCLE17,7C-1
MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
CLIENT INFORMATION NOTICES
1.
MEDI-CAL DIALYSIS SUPPLEMENT SPECIAL TREATMENT PROGRAM
2.
MEDI-GAL TOTAL PARENTERAL NUTRmON (TPN) SUPPLEMENT
SPECIAL TREATMENT PROGRAM
FORMS
1.
MC 176D
MEDI-CAL SPECIAL TREATMENT PROGRAMS
PERCENTAGE OBLIGATION COMPUTATION
2.
MC 239F
NOTICE OF ACTION
MANUAL U 3 T E R NO.:
187
DATE: Sept.l8,1997
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MEDI-CAL ELlGIBlLlTY PROCEDURES MANUAL
BACKGROUND
1.
State law provides limited M e d i i l coverage to persons who need special types of life sustaining
medical treatment Such individuals are obligated to pay a percentage of the treatment costs for
services not covered by other insurance or other government programs, based on their net worth.
These special provisions are limited to persons in need of kidney dialysis or parenteral
hyperalimentation treatment (also known as total parenteral nutrition or TPN). TPN provides total
nutrient repiacement through a catheter positioned m the chest for persons who, b r whatever reason,
are unable to eat and digest food.
2
.
DEFINITION OF DIALYSIS AND RELATED SERVICES
D
iand related swvices are defined in Tie 22, California Code of Regulations, Section 51157,
and are a s follows:
A
Renal Diilysis
"Renal disis"means removal by artificial means of waste products normally excreted by
the kidneys. Such removal may be accomplished by the use of an amaal kidney or
peritoneal dialysis on a continuing basis.
w:Renal dialysis indudes fullcare, self-care,or homecare dialysis.
B.
Related Services
" R e W Services" means hospital inpatient and physician's services related to the treatment
of renal failure, stabilization of renal failure, teatmmt of complications of dialysis, and diatysis
related laboratory tests, medical supplies, and drugs.
3.
DEFlNmONS OF TYPES O f DIALYSIS
A
Full Care Dialysis
Full-care dialysis is provided in a dialysis dinic or a hospital outpatient clinic. Treatment is
fully managed by staff;the patknt takes no part in managing his or her own care.
B.
Self-Care Dialysis
Self-care dialysis takes place in a "selfcare dialysis unit" of a dialysis clinic or hospital
outpatient clinic. The patient manages his or her own treatment with less sWf supervision
required.
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C.
Home Dialysis
Home dialysis takes place in the home. The patient has a home dialysis unit and dialyzes
at home. Usually a dialysis clinic or outpatient hospital dinic will supewise the patient's home
care and will provide needed supportive services,including the services of q u a l m home
dialysis aides on a seiective basis.
4.
BENEFICIARY PORTION OF SPECIAL TREATMENT PROGRAM COSTS
Special Treatment Program beneficiaries must pay a percentage of the cost of each diatysis or TPN
service. The percentage is based on their annual net w o r n combination of property and annual
gross income (some property is exempt). The "percentage obligation" that these beneficiaries must
pay is indicated on the Point of Service (POS) device when the provider verifies patient eligibiii
through the Automated Eligibility Verification System (ANS). The provider uses that percentage
figure to calculate what the beneficiary qwes on each service. Patients who are Special Treatment
Program-Supplement beneficiaries are also enWed to use that amount towards meeting the regular
MediiCal share of c o s t
5.
OTHER HEALTH COVERAGE AND B l W N G PROCESS
If the patient has Medicare, private health insurance, or any ather nokhllediial coverage, that
coverage must be bilied first for the cost of a TPN or dialysis senrice. Counties are required to enter
appropriate Other Health Coverage (OHC) codes on Medi-Cal Eligibility Data System (MEDS) and
obtain a completed Health Insurance Questionnaire form (DHS 6155) as needed for this poputation
when heafth insurance is available or has c h a ~ g e d .The patient's percentage obligation applies to
the balance remaining after payment by such other coverage. For example, if Medicare covers $80
of a $100 charge,the patient's percentage obligation will be applid only to the remaining $20. The
provider subtracts what the beneficiary owes from the $20 and Mis Medi-Cal for the rest
6.
MEDS PROCESS
Special Treatment Program records must be added to MEDS by the county using either
online or batch transactions. The Medi-Cal Special Treatment Program-Percentage Obligation
Computation, Form MC 176D. (Exhibit A) will continue to be used to determine the percentage
obligation for applicants of Special Treatment Programs. It must be completed at the time of a new
application, restoration, reappiication, change in net worth affecting percentage obligation, and
redetermination.
All
The MC 176D forms should not be fonnrarded to the Department of Health Sewices. Countiesshould
retain the original MC 176D in the case folder.
MANUAL LETTER NO.:187
SECTION NO.: 50801,50831
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MEDICAL ELIGIBILITY PROCEDURES MANUAL
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17B
1.
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- ELIGIBILITY REQUIREMENTS AND PROCEDURES
SPECIAL TREATMENT PROGRAMS
- "Only"Group
Persons who need dialysis, or total parental nutrition (TPN), and related services may be eligible for
l i e d Medi-Cat Special Treatment Programs coverage if all of the following conditions are met in a
month:
o
In need of dialysis, or TPN, and related services;
o
Not eligible for regular Medi-Cal because of excess property;
o
Not currently eligible for Medicare if under age 65 (applies only to Dialysis);
and
o
Meet standard Medi-Cal requirements for citizenship or legal immigration status,
linkage, cooperation, and residency.
o
For TPN 'Only": Medi-Cal linkage requirements are not necessary.
NOTE: Retroactive Medi-Cal benefits are not available for the " O n v group.
Reporting Responsibiiiies
All applicants and beneficiaries must report any change in status that could affect their dialysis or TPN
program eligibilityor their percentage obligation. These include, but are not limited to:
o
Loss of employment (may be able to qualify for full scope M e d i i l disability if no longer
working and engaging in substantial gainful actrvity);
o
lncreaseldecrease in earnings;
o
Change in marital status:
o
Change in other health coverage; and
o
Change in property.
NOTE: If a M e d i i l Special Treatment Programs - Oniy beneficiary loses such program eligibility
because helshe becomes eligible for regular Medi-Cal, eligibility must also be determined under
Medi-Cal Special Treatment Programs-Supplement
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MEDI-CAL ELlGlBILrrY PROCEDURES MANUAL
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2.
SPEClAL TREATMENT PROGRAMS
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- "SupplementGroup*
Persons who need dialysis, or TPN, and related services and who a r e eligible for regular Medi-Cal
may also be eligible for limited M e d i i l Special Treatment Programs coverage if all of the following
conditions are met in a month:
o
In need of dialysis, or TPN, and related services;
o
Receiving either home dialysis or s e w r e dialysis;
o
Employed or setfemployed, with gross monthty earnings which are greater than the
individual Medi-Cai maintenance need for one person;
o
OtheNvise eligible for Medi-Cal Medically Needy or Medically Indigent program with a share
of cost,and
o
Meet standard M e d i i l requirements for citizenship, legal immigration status, cooperation,
property and residency.
All applicants and beneficiaries must report any changes in status that could affect their dialysis or
TPN program eligibility or their percentage obligation. These indude, but are not liraited to:
o
Loss of employment;
o
Change in marital status;
o
Increaseldecrease in earnings;
o
Change in other health coverage; and
o
Change in property.
NOTE: If a Medi-Cal Special Treatment Programs--Supplement beneficiary loses such program eligibility
because of excess resources, eligibility must also be determined under Medi-Cal Special Treatment
Programs-Only.
3.
AID CODES
o
All eligibles for dialysis services should be reported to MEDS as aid code 71.
o
All eligibles for TPN services should be reported to MEDS as aid code 73.
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4.
INFORMATION ON MEDI-CAL DlALYSIS AND TPN SPECIAL TREATMENT PROGRAMS
This program provides medical cost relief for dialysis, TPN, and related services. Under the
regular Medi-Cal program, the beneficiaries must pay or obligate all their surplus income
toward meeting their share of cost for medical care. Under this program, they need to pay
only a percentage of the cost for diatysis or TPN services affer any other health coverage
payment is subtracted from the cost of those services.
B.
Dialvsis-Onhr Proaram Services
Ditysis "Only" covers retated hospital and physiaan services associated with the treatment
of renal failure, s t a b i i i o n of renal failure, treatment of complications of dialysis and
dialysis-related laboratory tests, medical supplies, and drugs.
C.
Diahrsis-Suo~krnent Prooram Services
Dialysis Supplement covers a wide range of diisis s e ~ c e exceot
s
routine full-care dialysis.
Routine fullcare dialysis is not a Dialysis Supplement benefit This exclusion does not
preclude provision of full care dialysis treatment in the case of a physician-cerWied medical
emergency.
TPN-Only covers inpatient hospital care directly related to TPN, induding home TPN
training, home TPN, and related services and supplies.
E.
TPN-SuCJ~lement -ram
Services
The TPN Supplement covers inpatient hospital care directly related to TPN,including home
TPN training, home TPN, and related services and supplies.
F.
How Diahrsis and TPN S u ~ ~ l e m e nRelate
ts
to Reaular Medial Eiioibilitv
D i s i s and TPN Supplements cover only the servicesdescribed in Sections C and E above.
If the beneficiaries or their families need other types of medical care, they must meet their
regular M e d i i share of cost before they can receive regular M e d i i l . The amount they
pay for diatysis, T P N or related services as part of the Dialysis or TPN Supplement program
will atso be a credit against their regular Medi-Cal share of cost, just the same as any other
medical bill they pay. Ditysis Supplement coverage ends when the beneficiaries meet their
regular M e d i i share of cost At that point,all medical services including dialysis or TPN,
will be billed under the regular Medi-Cal aid code for the remainder of the month.
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DATE:
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MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
5. DEERMINATIONOF ANNUAL NET WORTH FOR MEDJ-CAL SPECIAL TREATMENT PROGRAMS
The amount of the percentage obligation to be paid toward each dialysis, TPN or related service depends on
the annual net worth of the beneficiaries and their spouse or the beneficiaries and their parents if they are
under 18, unmarried, and living with their parents, Annual net worth is based on combined annual gross
income plus property holdings.
The percentage obligation is computed a s follows:
o
If the annual net worth is less than $5,000, individuals pay nothing.
o
The percentage obligation for Dialysis or TPN- -Only is two mrcent per each $5,000 of net
worth.
o
The percentage obligation for Dialysis or TPN- Supplement is one oercent per each $5,000
of net worth.
Persons in family units with a net worth of more than $250,000 are not eiigible for benefits
under the Special Treatment Programs.
The following are
1)
counted as part of the property holdings:
The first $40,000 of the fair market value of the applicants or beneficiary's home.
The remaining market encumbrances, shafl be induded in annual net worth
determination.
2)
One mator v e h i i used to meet the transportation needs of the individual or family.
3)
Lie or burial insurance purchased specifically for funeral, cremation, or interment
expense, which is placed in an irrevocable trust or which has no loan or surrender
value avaiiabk to the recipient
4)
Wedding and engagement rings, heirlooms, clothing, household furnishings and
equipment
5)
Equipinventory, licenses, and makrhb owned by the appiicant or beneficiary
which are necessary for employment, for self-support, or for an approved plan of
rehabiUtationor self-care necessary for employment
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17C-MEDICARE EUGIBIUTY AND THE MEDl-CAL DIALYSIS
SPECIAL TREATMENT PROGRANlS
I.
IMPORTANCE OF MEDICARE FOR DlALYSlS EUGIBLES
Counties must closely monitor the Medicare eligibility of diatysis cases for the following reasons:
A
A Dialysis-Only beneficiary who is under 65 loses Dialysis-Onty eligibility once Medicare
eligibility is established.
11.
B.
AJthough DiahrsisSu~~lementeligibility does not end when Medicare eligibility is
established, Medicare takes over most of the dialysis costs from that point
C.
Medicare eiiiibilii does not affect eligibility for Mediial Special Treatment
Programs-Supplement
MEDICARE ELlGlBlUTY REQUIREMENTS FOR DlALYSlS PATIENTS
To be eligible for the Medicare Dialysis program:
Ill.
A
The individual must be fully or m n U y insured under Soda1Secmity or must be the spouse,
dependent child, fonner spouse, widow, etc., of an insured individual. Fully insured
individuals have 40 calendar quarters of covered employment under Social Security;
current& insured individuals must have 6 out of the past 13 calendar quarters of covered
employment under Social Security.
B.
The individual must be suffering from chronic kidney failure.
C.
The individual must apply with Social Security for Medicare benefits.
WAITING PERIOD FOR MEDICARE COVERAGE
There is a three-month waiting period between onset of chronic kidney failure and the beginning of
Medicare coverage. However, patients who are eligible for Medicare Dialysis may have the coverage
begin as soon as their application is completely processed by Social Security as follows:
A
Individuals who enter self-care
or home dialysis training at any time during the three-rnonth
waiting period will have the entire waiting period waived; their Medicare coverage begins with
the &t month of treatment for chronic kidney failure.
B.
Medicare coverage is retroactive, for up to 12 months before application, if the person met
the coverage criteria in the past months. So a person whose Medicare application is not
approved until the fourth month aRer kidney failure sets in, would have coverage start at the
time of application, providing that the person met the eligibility criteria requirements for the
Dialysis program.
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N.
MONITORING CHANGES IN MEDICARE ELIGIBILITY
Backaround Information
I.
Medicare Application
Social Security district offices generally expedite the applications of persons in need
of dialysistSWf usually are able to evaluate the information given and to
inform Ute applicant whether it appears there will be eligibility for Medicare, either at
the time of application or shortly themfter. Under certain circumstances, however,
a Medicare eligibility determination may become complex, and a timety evaluation
is not possible.
In most cases, Social Sesaity will inform applicants whether o r not they are eligible
for Medicare within three months of application. If there has been no response
received by the end of the third month, the applicant must &edc with Social Security.
2.
Calendar Quarters of Coverage
Upon request Social Security will provide to ind- duals a statement of their quarters
of covered employment called "Quarters of Coverage". S o d Security reports may
understate quarters of coverage by up to one year (four quarters) for currently
employed persons. An estimate of how many quarters of coverage are required
before an employed p e m , or covered dependent, will become eligible for Medicare
can be made by subtracting the number of existing quarters of coverage from the
number of required quarters.
For exampie, a person with 2 quarters of coverage may only have to work in a job
covered under Social Security for one additional year (or 4 calendar quarters) to
have the required 6 out of the last 13 calendar quarters of coverage to become
eligible for Medicare. Similarly, a person with no quarters of coverage would have
to work for 18 months to become eligible for Medicare.
1.
Applicants must apply for Medicare coverage within ten days of making application
for a Special Treatment dialysis program, unless they provide a current Social
Security statement of Medicare status. Failure to do so without good cause will
result in denial of the application.
2.
Special Treatment Diiiysi program beneficiaries must provide the county with a
copy of the soc'lill Security statement of Medicare siatus, or any evidence of
eligibility such as a card or letter, within ten days of receiving such evidence.
3.
Beneficiaries shall cooperate with the county as requested if there has been no
response to their Medicare application within three months of the application date.
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C.
IV.
4.
Beneficiarieswho are determined to be wrrentty not eligible for Medicare, but who
are employed or are the spouse or dependent child of an employed person, shall
request a statement of Quarters of Coveraae from Social Security and shall provide
this information to the county weKare department (Social Security "Benelit Estimate
Form".)
5.
Beneficiaries are required to complete and return a Medi-Cal Status Report every
calendar quarter. They will frequentfy use this form to tell the county for the first time
of a change in Medicare status.
COUNTY RESPONSlBlLmES
1.
The county shall review the facts it has received on the beneficiary's Medicare sWus
at the time the first quarteriy status report is s e n t If the result of a Medicare
application has not been reported by then, the county shall: (1) require the
beneficiary to follow up with Social Security and report to the county or (2) inquire
d m of Social Security regarding the beneficiary's W i r e status via the "Social
Security-Public Assistance Agency Information Request and Report" (SSA 1610).
2.
ihe county shall reevaluate eligibility when information on Medicare status
is received. Nledi-Cal Diiiysb Only beneficiaries who are under 65 wiIl be ineligible
for program benefits once Medicare coverage begins.
3.
The county shall report the Health insurance Claim (HIC) number for all continuing
Medi-Cal Special Treatment Program dialysis beneficiaries on the MC 176D when
Medicare coverage is established.
4.
The county shall set up a reevaluation "tickler"date based on the number of calendar
quarters of coverage required for beneficiaries to become eligibie for Medicare in the
future. Eligibility shall be reevaluated in the month it appears the beneficiary will
become eligible for Medicare.
RETROACTIVE MEDICARE COVERAGE AND MEDLCAL OVERPAYMENTS
As noted eariier, Medicare Dialysis coverage far a person may be retroactive. A Medi-Cal
Special Treatrnent Program dialysis beneficiary may therefore be retroactively eligible for
Medicare for the same period that Medi-Cal has already paid for dialysis treatment As long
as the beneficiary has met the Medicare application and verification requirements of the
diaiysis programs in a timely manner, such payments will not be considered overpayments
by Medi-Cal. In addition, the Medi-Cal program is allowed to bill Medicare for its share of
retroactive coverage.
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MEDI-CAL DIALYSIS SUPPLEMENT
SPECIAL TREATMENT PROGRAM
CLIENT INFORMATION NOTICE
Notice Information Date:
Case No.:
Worker NameMo .:
Worker Telephone No.:
Name:
If you need kidney dialysis and qualify for the Medi-Cal Dialysis Supplement Special Treatment
Program,that program could reduce your out-of-pocket dialysis costs. Here are key facts and rules
about the program.
I.
Dialvsis Su~~lement
EliPibilitv Reauirernents
You must meet all of the following conditions in a month:
In need of dialysis.
Eligiile for reg& Medi-Cal with a personal or famity share of cost.
Employed, or self-employed, with gross earnings which are greater than the
individual Medi-Cal maintenance need for one person.
Receiving either home dialysis or selfkae clinic dialysis.
11.
Information for Dialvsis S
A.
ement P r o m
Advantwe of Dialvsis Supplement Program
This program provides you medical cost relief for dialysis and related services.
Under the regular Medi-Cal program, you must pay all your surplus income toward
myour share of cost for medical care. Under this program, you need pay only
a percentage of the cost for dialysis senices after any other health coverage payment
is subtracted from the cost of those senices.
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B.
Usins Your Other Health Coverace
-
If you have Medicare, private health insurance, or any other non-Medi-Cal coverage,
that coverage must be billed firstfor the cost of a dialysis service. Your percentage
obligation applies to the balance remaining after payment by such other coverage.
For example, if Medicare covers $80 of a $100 charge, your percentage obligation
will be applied only to the remaining $20. The provider subtracts what you owe
from the $20, and bills Medi-Cal for the rest.
C.
What You Pav Toward the Cost of Your Dialvsis Care
The amount you pay toward each dialysis service depends on the m u a l net worth
of you and your spouse, or you and your parents if you are under 18. Annual net
worth is annual income plus property holdings. The following are not counted as
part of your property holdings:
The first $40,000 of the fair market value of your home; one motor vehicle used to
meet the transportation needs of you or your family; life or burial insurance
purchased specifically for funeral, cremation, or interment expense, which is placed
in an irrevocable trust or which has no loan or surrender value available to you;
wedding and engagement rings, heirlooms, clothing, household furnishings and
equipment; equipment, inventory, licenses, and materials owned by you which are
necessary for employment, for seIf-suppoq or for an approved plan of rehabilitation
or self-we necessary for employment
If your annual net worth is less than $5,000, you pay nothing. If it is $5,000 or more,
you pay one percent of the net cost of each dialysis service for each $5,000 of annual
net worth you have. For example, if your annual net worth is $15,000, you pay three
percent of the net costs of each dialysis service. The percent you pay is called your
"percentage obligation."
D.
How Your Dialvsis Supplement Eli9ibiIitv Fits into Your Rermlar Medi-Cal
Eligibility
Dialysis Supplement covers dialysis and r e k d services only. If you or your family
need other types of medical care, you must meet your regular Me&-Cd s h of cost
before Medi-Cal will pay for covered services. The amount you pay for dialysis and
related senices as part of your Dialysis Supplement eligibiity will be a credit against
your share of cost, just the same as any other medical bill you pay. Dialysis
Supplement coverage ends when you meet your regular Medi-Cal share of cost. At
that point, d medical services including TPN Supplement will be billed under your
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reguiar Medi-Cal coverage for the remainder of the month.
E.
What Happens if You Lose R d a r Medi-Cal Eliebiiitv
Eligibility for Dialysis Supplement depends on eligibility for the re-dar Medi-Cal
program. If you lose eligibility for regular Medi-Cal for any reason, including
accumulation of excess resources, you will no longer be eligible for Dialysis
Supplement. In this case, the county welfare department will determine your
eligibility mder the Dialysis Only Program.
III.
Services Covered bv the Me&-Cal Dialvsis Smlernent P r o m
A.
Dialvsis Suaplement Benefits
The Medi-Cal Dialysis Supplement program coversthe fullrange of dialysis senices
except routine full-care dialysis. Routine fill-care dialysis is not a Dialysis
Supplement benefit This exclusion does not preclude provision of fullare dialysis
treahnent in cases of a physician &ed
medical emergency. Dialysis Supplement
coverage ends when you meet your regular Medi-Cal share of cost, since for the rest
of the month you are entitled to fke Medi-Cal senices, including routine W-care
dialysis.
B.
Definition of Dialvsis and Related Services
Dialysis and related services are defined in Title 2.2,Wornia Code of Regulations,
Section 51157 as follows:
"(a)
Renal dialysis' means removal by artificial means of waste products normally
excreted by the kidneys. Such removal may be accomplished by the use of
an artificial kidney or peritoneal dialysis on a continuing basis.*
"(b)
'Related services' means hospital inpatient and physician's senices related to
the treatment of renal failure, stab'ition of renal failure, treatment of
complications of dialysis, and dialysis related laboratory tests, medical
supplies, and drugs."
*(Note: "Renal dialysis" means full-we, self-care, or home-care dialysis.)
C.
Definitions of T y x s of Dialvsis
1.
. Full-care dialysis is provided in a dialysis clinic or a hospital outpatient
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clinic. Treatment is fully managed by M,the patient takes no part in
managhg his or her own care.
IV.
2.
Selfcare dialysis takes place in a "self-care dialysis unit" of a dialysis clinic
his or her own treatment
or hospital outpatient clinic. The patient =es
with less staffsupenision required.
3.
Home dialysis takes place in the home. The patient has a home dialysis unit
and dialyses at home. Usually a dialysis clinic or outpatient hospital clinic
will supenise the patient's home care and wiU provide needed supportive
services, including the services of @ed
home dialysis aides on a selective
basis.
Your Responsibilities
A.
B.
Medicare Aplication
1.
You must apply for Medicare coverage within ten'days of making application
for this p r o m unless you already have Medicare coverage or have a
statement fiom Social Security showing you are currently not eligible for
Medicare.
2.
You must provide the county welfire department a copy of the Social
Security Medicare status, or any evidence of eligibility such as a card or
letter, within ten days of receipt.
3.
If you are not currently eiigible for Medicare, you must request a statement
of auarters of coverage from Social Security (Social Security Benefit
Estimate Form). You should determine, with the aid of a Social Security
representative, how many more quarters of coverage you need to become
eligible for Medicare. This infomation must be given to the county welfare
department or your eligibiity will have to be redetermined every quarter. &
is vour direct advantage to apply for Medicare as soon as vou believe vou are
eligible. The cost you must pay is based on the balance left after Medicare
or any other insurance has paid. Medicare coverage can reduce your cost up
to 80 percent.
General Reporting Remonsibilities
You must report any change in status that could affect your dialysis program
eligibility or your percentage obligation. These include, but are not limited to:
SECTION NO.: 50801,50831
DATE:
MANUAL LETTER NO.: 187
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S&;18,1997
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17C-7
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MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
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Loss of employment.
Change in marital status.
Increaseldecreasein earnings.
Change in other health coverage.
Change in property.
I have reviewed the above i n f o d o n with the c o w representative. I understand my
responsibiiities in regard to Medicare and general reporting requirements.
Date
Applicant
I have explained the Medi-Cal Dialysis Supplement requirements listed above to the applicant.
County Representative
SECTION NO.: 50801,50831
Date
MANUAL LETTER NO.:
187
DATE:
17C8
Sent. 18.1997
MEDI-CAL ELlGlBlLlTY PROCEDURES MANUAL
MEDI-CAL TOTAL PARENTERAL NUTRITION (TPN)
SUPPLEMENT SPECIAL TREATMENT PROGRAM
CLIENT INFORMATION NOTICE
,
Notice Wormation Date:
Case No.:
Worker NameLNo.:
Worker Telephone No.:
Name:
If you require parented hyperalimentation treament, also known as total parented nutrition
(TPN), and qualify for the Me&-CaI TPN Supplement program, that program could reduce your
out-of-pocket TPN costs. Here are key facts and rules about the program.
I.
TPN SuppIement EIi5biIitv Requirements
You must be all of these things in a month:
In need of TPN.
Performing home TPN treatment.
Eligible for regular Medi-Cal with a personal or family share of cost.
Employed, or =If-employed, with gross monthly earnings which are greater than the
individual Medi-Cal maintenance need for one person.
II.
Information for TPN Supplement Eligibles
A.
Advantages of TPN Swlement Pro-
This program provides you medical cost relief for home TPN tieatment. Under the
re,&
Medi-Cal program, you must pay all your surplus income toward meeting
your share of cost for medical care. Under this program, you need pay only a
percentage of the cost for home TPN treatment after any other health coverage
payment is subtracted fiom the cost of those services.
SECTION NO.: 50801,50831
MANUAL LETTER NO.: 187
DATE:
17C-9
MEDI-CAL ELlGIBfLITY PROCEDURES MANUAL
B.
Usins Your Other Health Coverace
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If you have Medicare, private health immnce, or any other non-Medi-Cal coverage,
that coverage must be utilized or billed first for the cost of home TPN treatment.
Your percentage obligation applies to the balance remaining after payment by such
other coverage. For example, if Medicare covers $80 of a $100 charge, your
percentage obligation will be applied only to the remaining $20. The provider
subtracts what you owe from the $20 and bills Medi-Cal for the rest.
C.
What You Pav Toward the Cost of Your Home TPN Treament
The amount you pay toward your home TPN treatment depends on the annual net
worth of you and your spouse, or you and your parents if you are under 18. Annual
net worth is annual income plus property holdings., The following are not counted
as part of your property holdings:
The first $40,000 of the fair market value of your home; one motor vehicle used to
meet the transportation needs of you or your family; life or burial insurance
pmhased speci.ficallyfor funeral, cremation,or interment expense, which is placed
in an irrevocable trust or which has no loan or surrender value a m b l e to you;
wedding and engagement rings, heirlooms, clothing, household furnishings and
equipment;and equipment, inventory, licenses, and materials owned by you which
are necessary for employment, for self-support, or for an approved plan of
rehabilitation or self-care necessary for employment.
If your annual net worth is less than $5,000, you pay nothing. Kit is $5,000 or more,
you pay one percent of the net cost of your home TPN treament costs for each
$5,000 of annual net worth you have, For example, if your annual net worth is
$15,000, you pay three percent of the net costs of your home TPN treament costs.
The percent you pay is called your "percentageobligation".
D.
How Your TPN Supplement Eliaiility Fits into Your Regular Medi-Cal Elimiility
TPN Supplement covers home TPN supplies and related senices only. If you or
your family need other types of medical care, you must meet your regular Medi-Cal
share of cost before Medi-Cal will pay for covered services. The amount you pay for
home TPN supplies and related services as part of your TFW Supplement eligibility
will also be a credit against your regular Medi-Cal share of cost,just the same as any
other medical bid1 you pay. TPN Supplement coverage ends when you meet your
regular Medi-Cal share of cost. At that poinq all medical services including TPN
Supplement will be billed under your regular Medi-Cal coverage for the remainder
SECTION NO.: 50801,50831
187
MANUAL LElTER NO.:
DATE:
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Cant
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17C-10
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MEDIdAL ELIGIBIL1TY PROCEDURES MANUAL
of the month.
E.
What Hapens if You Lose Regular Medi-Cal Eligibility
Eligibility for TPN Supplement depends on eligibility for the regular Medi-Cal
program. If you lose eligibility for regular Medi-Cal for any reason, including
accumulation of excess resources, you will no longer be eligible for TPN
Supplement In this case, the county welfare department wiIl determine whether you
are eligible under ~e TPN Only program.
III.
Services Covered bv the Me&-Cal TPN Supplement Special Treazment Program
A.
TPN Sm~lementBenefits
The TPN Supplement Special Treatment Program covers only a limited range of
outpatient benefits. You may use your TPN Supplement for approved nutrient
solutions and related supplies, related laboratory services, and outpatient physician
visits.
If you require treatment for an underlying condition, acute hospital care, or other
forms of medical care, you must meet your regular Me&-Cal share of cost before
Medi-Cal will pay for these services.
IV.
Your Remonsibilities
A.
Medicare A~~lication
You must apply for Medicare coverage after you apply for this program if you are
receiving Social Security Title II Disability benefits.
You must provide the county w e k e department with a copy of the Social Security
Medicare status statemenf or any evidence of eligibility such as a card or letter,
within 60 days of your Medicare application. If Socid Security does not provide you
with a Medicare status statement within 60 days, you must provide a copy to the
county welfare department as soon as you do receive it.
B.
General Reportino Res~onsibilities
You must report any change in status that could affect your TPN Supplement Special
Treatment Program eligib'ity or your percentage obligation. Such changes include,
but are not limited to:
SECTION NO.: 50801,50831
MANUAL L-R
NO.:
187
DATE:
.
17C-11
Sept 18,1997
MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
Loss of employment.
Change in marital status.
hcrease/decreaseinearnings.
Change in other health coverage.
Change in property.
I have reviewed the above information with the c o w representative. I understand my
responsibilities in regard to Medicare and general reporting requirements.
Date
Applicant
I have explained the Medi-Cal TPN Supplement requirements listed above to the applicant.
Date
County Representative
SECTION NO.: 50801,50831
MANUAL LEllER NO.:
187
DATE:
Se~t.18,1997
17G12
MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
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AfEDCCAL SPEClAL TREATMENT PROGRAMS-PERCENTAGE OBUGATION COMPUTATION
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Am-
SECllGili N.?.: 50801-
50831 MANUAL LEITER NO.:
187
DATE:
Se~t.18.1997
17C-13
MEDICAL ELiGIBILiTY PROCEDURES MANUAL
I-
MEDCCAL
NOTICE OF ACTION
MEDCCAL SPEClAL IREANEN7 PROGRAMS
Naris-
case-
Ywr obligatbn ate is
d e r m t o b f $
~ntperS5.000onannsalnetworthupro#50.600. Y o u r ~ n e t w o r V I w a s
for the b e h w m d h periodfrom
thrwgh
This means lhatthe persnorcuga&abnprwidingyouwithsuppiies and services winsend abmformcostto
Your innaante m.
or to any other agency that prwides yov with coverage for these srrpplies and servites.
YwwilIpayor~e
percent ot the cwt NOT paid by the imumce company or other agency. tt you
havenoinaranceorother'c~vegge.puw9payorobSgate
percent ol the entire a s of the s e e . The
costs notpaid byyarrbrnaanceorothercoveage,orpaidorob~byyou,Wbepaid by-
-
0
Y o u r m g f
Rogfarn because:
0
Your eligbllity has been drscontiwed for the ~edi-CaI: D D
efledite
hasbeendeWforYheMebi~DWysis OTFNSpe&lTraamrem
i
i
0 *N
Special Treatment Program
The regutatiorr;whichrequirethisactbnare Catifornia Code of R e g u l a t i o r # ~ 2 2 . ~ s ) :
You must notify the county wetfare department within ten days of anj. changes in income. propew. or o!her
dreumstances. lf you have-othernredcal ewerage, it mrst be used before MediCaL Faaure to tell the courny w&m
W n I about other h e m care coverageor fabae to use other carerage avabbk to you is a rrrisdemearm.
UyoUhave~q~esbknsaboutthis~~rifthereatead&tiorratfactsrefatingtoyozrr~whichyouhave
not reported to us. please write or teiephone. We wilI m
r your questions or make an appobmnent to see MI in
person.
PLEASE READ THE REVERSE SIDE OF 7HS NOnCE
SECTION NO.:
50801-50831 MANUAL LETTER NO.: 187
DATE:
.
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17C-14
MEDI-CAL ELIGIBILITY PROCEDURES MANUAL
YOUR HEARING RIGHTS
HOW TO ASK FOR A STATE HEARING
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SECTION NO.:
50801
- 5 0 8 3 1 ~ LETTER
U ~ NO-: 187
DATE:
DM-
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